CT HMIS SNOFO DMHAS/DDaP/Street Outreach Discharge Form (To download this form, click here)

Applicant (Head of Household) Information:

Project Exit Date:                          HMIS Client ID#:          

First Name:                          Last Name:                         

Middle Name:                          Suffix:                 

Cell Phone:                       Home Phone:                         

Work Phone:                          Email:                         

Housing Move – In Date:                         

Exit Destination Type:

  • Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station, airport or anywhere outside)
  • Safe Haven
  • Psychiatric Hospital or other psychiatric facility
  • Substance Abuse treatment facility or detox center
  • Hospital or other residential non-psychiatric medical facility
  • Jail, prison, or juvenile detention facility
  • Foster care or foster care group Home
  • Long-term care facility or Nursing Home
  • Transitional housing for homeless persons (including homeless youth)
  • Rental by client, no ongoing housing subsidy
  • Owned by client, no ongoing housing subsidy
  • Staying or living with family, temporary tenure (e.g., room, apartment, or house)
  • Staying or living with friends, temporary tenure (e.g., room, apartment, or house)
  • Hotel or Motel paid for without Emergency Shelter voucher
  • Rental by client, with ongoing housing subsidy

IF Rental by client, with ongoing housing

Subsidy is Checked, Please select Subsidy from List:

  • GPD TIP housing subsidy
  • VASH housing subsidy
  • RRH or equivalent subsidy
  • HCV voucher (tenant or project-based) (not dedicated)
  • Public housing unit
  • Rental by client, with other ongoing housing subsidy
  • Emergency Housing Voucher
  • Family Unification Program Voucher (FUP)
  • Foster Youth to Independence Initiative (FYI)
  • Permanent Supportive Housing
  • Other permanent housing dedicated for formerly homeless persons
  • Other
  • Deceased
  • No exit interview completed
  • Client doesn’t know
  • Client Prefers Not to Answer
  • Data Not Collected

Shared Housing Information:

(Shared housing means clients will be on separate leases or living as roommates. Not clients living together as a couple)

Is this a Shared Housing Destination (separate leases)? Yes No

If Yes, Shared Housing Facilitated by: CAN Client

Non-Cash Benefit from any source? No Yes Client doesn’t know Client Prefers Not to Answer Data Not Collected

If yes, Non-cash benefit source is required. Check those that apply:

  • Supplemental Nutrition Assistance Program (SNAP) (Previously known as Food Stamps)
  • Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
  • TANF Child Care Services
  • TANF Transportation services
  • Other TANF-funded services
  • Other Source: Specify if Other:                   

Covered by Health Insurance: No Yes Client doesn’t know Client Prefers Not to Answer Data Not Collected

Disabling Conditions

Substance Abuse Disorder: No Alcohol Abuse Drug Abuse Both Alcohol and Drug Abuse Client doesn’t know Client Prefers Not to Answer Data Not Collected

If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?

  • No
  • Yes
  • Client doesn’t know
  • Client Prefers Not to Answer
  • Data Not Collected

Physical Disability: No Yes Client doesn’t know Client refused Data Not Collected

If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?

  • Yes
  • No
  • Client Doesn’t Know
  • Client Prefers Not to Answer
  • Data Not Collected

Developmental Disability: No Yes Client doesn’t know Client Prefers Not to Answer Data Not Collected

Chronic Health Condition: No Yes Client doesn’t know Client Prefers Not to Answer Data Not Collected

If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?

  • No
  • Yes
  • Client doesn’t know
  • Client Prefers Not to Answer
  • Data Not Collected

HIV/AIDS: No Yes Client doesn’t know Client Prefers Not to Answer Data Not Collected

Mental Health Disorder: No Yes Client doesn’t know Client Prefers Not to Answer Data Not Collected

If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?

  • No
  • Yes
  • Client doesn’t know
  • Client Prefers Not to Answer
  • Data Not Collected

Translation Assistance:

Translation Assistance Needed? Yes No Client doesn’t know Client Prefers Not to Answer Data Not Collected

If yes, Preferred Language:                   

Health Insurance (If yes, select which applies):

MEDICAID State Health Insurance for Adults
MEDICARE Private Pay Health Insurance
State Children’s Health Insurance Program (CHIP) Indian Health Services Program
Veteran’s Health Administration (VHA)
Employer-Provided Health Insurance If Other, Specify:          
Health Insurance obtained through COBRA

Income received from any source?

Yes No Client doesn’t know Client Prefers Not to Answer Data Not Collected

Income Type Monthly Amount Income Type Monthly Amount
Unemployment Insurance N Y $ VA Non-Service-Connected Disability Pension N Y $
Earned/Employed Income N Y $ Pension or Retirement income from a former job N Y $
Supplemental Security Income (SSI) N Y $ Child Support N Y $
Social Security Disability Insurance (SSDI) N Y $ Alimony or other spousal support N Y $
VA Service-Connected Disability Compensation N Y $ Worker’s Compensation N Y $
Private Disability Insurance N Y $ Other Source: Specify: N Y $
Retirement Income from Social Security N Y $
General Assistance (GA) N Y $
Temporary Assistance for Needy Families (TANF) N Y $ Client Income Total $

DMHAS Specific Questions (*= Required Information):

*Discharge Reason:

  • AWOL for Inpatient only
  • Death
  • Evaluation Only
  • Incarcerated
  • Inpatient Discharge for Inpatient Medical Tx
  • Client Discontinued Tx
  • AMA
  • Left Against Advice
  • Moved out of area
  • Non-compliance with rules
  • Recovery Plan Completed
  • Released by Court
  • Discharged to New Service (Facility Concurs)
  • Other
  • Unknown

Service Type:

  • T1016 – Case Management with Client Face to Face
  • T116C – Case Management with Client By Telephone
  • T116B – Case Management with Collateral